WQ 2023 Registration

We're so excited that you're joining us for WQ!

If you have any questions or problems with this form, please contact Ben: ben.vinje@ndcef.com

Contact Information

Preferred First Name/Nickname & Last Name

Legal first name (if different than name listed above)

Age (as of January 20, 2023)

Gender

Male Female

Grade in School (2022-2023 year)

Student Phone

Birthdate

Email (Please make sure this is a valid email address that gets checked! This is where we will send your confirmation email + later details and updates!)

This address will receive a confirmation email

Mailing Address

Church Name & Town (if applicable)

School Name & Town

Parent/Guardian Full Name

Parent/Guardian Phone Number

Emergency Contact (other than parent listed)

Emergency Contact Relationship to Student

Emergency Contact Phone Number

Local CEF Chapter (if known)

Northeast Southeast Northwest Southwest Williston Basin Fargo-Moorhead I'm not sure

Shirt Size (adult men's)

Transportation

CEF provides transportation from the following cities. Please choose the meeting point you plan to use. More information about times and locations will be provided to you as WQ gets closer.

From where will you be riding the bus TO WQ?

Where will you be dropped off AFTER WQ?

Medical Info & Permissions

Does the registrant have health insurance at this time?

Health Insurance Carrier (if applicable)

Subscriber Name (if applicable)

Policy #

Group #

Please list any dietary restrictions/food allergies:

Please list any non-food allergies:

Please list any other medical concerns:

Parent/Guardian, will you give permission for your child's picture to be taken for promotional purposes for CEF of ND, Inc? (By clicking

By digitally signing your name below, you verify that you agree with the following: "I understand that every precaution to ensure my childâ€™s safety and well-being during this event has been taken. I hereby release Child Evangelism Fellowship of North Dakota, Inc., its agents and employees from any and all liability for all personal injuries known or unknown that my child may incur while participating in activities conducted, sponsored, or associated with this event. In the event that I cannot be reached in the case of emergency, I authorize a physician selected by the coordinator of this event to administer emergency treatment."

Payment

Amount

Please describe any special payment instructions (if applicable):

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

WQ 2023 Registration

Description

Please Fix the Following